Human Rabies Surveillance Notification Form
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ScribdTranslationsHuman Rabies Surveillance Notification Form
Translated by
ScribdTranslationsNATIONAL PUBLIC HEALTH SURVEILLANCE SYSTEM
SIVIGILA Information Subsystem
Notification form
Human rabies code INS: 670
RELATO
INSHP
IWT
IHBASC
IDATA REG-R02.003.0000-020 V:02 YEAR 2012
A. Patient's names and surnames [Link]* C. Identification number
*TIPODE ID: 1 - RC : REGISTRO CIVIL| 2 - TI : TARJETADE IDENTIDAD | 3 - CC : CÉDULACIUDADANÍA| 4 - CE : CÉDULAEXTRANJERÍA| 5 - PA: PASAPORTE | 6 -MS : MENORSIN ID | 7 -AS :ADULTOSIN ID
D
[Link]
INORCONTACT
5.1 Type of aggression or contact 5.2Typeofinjury
5.1.1 Which other? Unknown
Bite Scratch or scrape [Link]
Unqiue
[Link] [Link] [Link]
Multiple
5.3 Depth 5.4 Anatomical localization (indicate more than one case if necessary)
Superficial Deep Unknown Head-face-neck Hand - finger Trunk Upper Limb Lower limb Unknown
6E
. XPOSUREDATAANDTYPEOFAGGRESSOR
6.1. Fecha de la agresión o contacto (dd/mm/aaaa) [Link] of the exhibition
/ / Openspace [Link] Unknown
6.3 Tipo de agresor Dog [Link] [Link](pig) [Link] [Link] [Link]
[Link] [Link] [Link] [Link] [Link]
6.4 Confirmed rabid animal by laboratory? 6.5 Confirmatory diagnostic test 6.5.1 Which other one?
IFD Immunohistochemistry
Yes [Link] 3 Unknown
[Link] [Link]
C
[Link]
IC
IALDA
TA
7.1 Signs and symptoms Fever 8D
.ysphagai [Link]
[Link] [Link] [Link]
[Link] [Link]/Hyporeflexia 17D
. yspnea
[Link] [Link]/Hallucination [Link]
5. Paresthesias [Link] [Link]
6. Paresthesias [Link]
7.1.1 Which other?
[Link] Sialorrhea
L8A
. BORA
TORY
ANDTREA
TMENTDA
TA
8.1Typeofsamplesent
Serum [Link] [Link] [Link]
[Link] [Link] [Link] 8.1.1 Which other?
8.2Sampledestination: 8.3 Confirmatory diagnostic test
N
1I.S [Link] [Link]
[Link] 8.2.1 Which other? [Link] [Link] 8.3.1 Which other?
8.4Result 8.5 Variant identification
Positive [Link] Inadequate [Link] Yes No [Link]
8.6 Identified variant 8.6.1 Which other?
1 5
8.7 Application of serum 8.8 Date of serum application (dd/mm/yyyy)
3 8
4 Another
Yes [Link] / /
8.9 Application of 8.10 Number of doses administered 8.12 Date of last dose (dd/mm/yyyy)
8.11 Date of first dose (dd/mm/yyyy)
vaccine
Yes 2N
.o
/ / / /
[Link]
9.1 Number of human contacts 9.2 Final classification of contacts: 9.3 Number of complete treatments applied
Health personnel Friends Mildexposures No exposure
Serum
Relatives Others Seriousexhibitions
Vaccine
correos:sivigila@[Link]/[Link]@[Link]
7535257127